Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SPINAL ANESTHESIA II

Facility

$958.00

Hospital Charge Code	8059590
Hospital Revenue Code	370
Min. Negotiated Rate	$478.81
Max. Negotiated Rate	$862.20
Rate for Payer: Aetna of IA Commercial	$862.20
Rate for Payer: Aetna of IA Medical Rental Products	$862.20
Rate for Payer: Aetna of IA Medicare	$546.06
Rate for Payer: Amerigroup Medicaid	$483.50
Rate for Payer: Amerigroup Medicare	$483.79
Rate for Payer: Cash Price	$766.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$718.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$479.00
Rate for Payer: Iowa Total Care Managed Medicaid	$478.81
Rate for Payer: Medical Associates Commercial	$718.50
Rate for Payer: Medical Associates Managed Medicare	$479.00
Rate for Payer: Midlands Choice Commercial	$670.60
Rate for Payer: Molina Healthcare Managed Medicaid	$486.18
Rate for Payer: Molina Healthcare Managed Medicare	$485.90
Rate for Payer: Oscar Health of IA Commercial	$718.50
Rate for Payer: Partners Health Alliance Commercial	$718.50
Rate for Payer: United Healthcare Commercial	$862.20
Rate for Payer: United Healthcare Managed Medicare	$565.22

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 ANESTHESIA III

Facility

$459.00

Hospital Charge Code	8059079
Hospital Revenue Code	370
Min. Negotiated Rate	$229.41
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: Aetna of IA Medicare	$261.63
Rate for Payer: Amerigroup Medicaid	$231.66
Rate for Payer: Amerigroup Medicare	$231.80
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.50
Rate for Payer: Iowa Total Care Managed Medicaid	$229.41
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$229.50
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$232.94
Rate for Payer: Molina Healthcare Managed Medicare	$232.80
Rate for Payer: Oscar Health of IA Commercial	$344.25
Rate for Payer: Partners Health Alliance Commercial	$344.25
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81

Spinal Disorders and Injuries With CC/MCC

Facility

$16,426.99

Service Code	MS-DRG 052
Hospital Charge Code	732
Min. Negotiated Rate	$16,188.92
Max. Negotiated Rate	$16,426.99
Rate for Payer: Amerigroup Medicaid	$16,347.63
Rate for Payer: Iowa Total Care Managed Medicaid	$16,188.92
Rate for Payer: Molina Healthcare Managed Medicaid	$16,426.99

Spinal Disorders and Injuries Without CC/MCC

Facility

$11,184.92

Service Code	MS-DRG 053
Hospital Charge Code	733
Min. Negotiated Rate	$11,022.82
Max. Negotiated Rate	$11,184.92
Rate for Payer: Amerigroup Medicaid	$11,130.89
Rate for Payer: Iowa Total Care Managed Medicaid	$11,022.82
Rate for Payer: Molina Healthcare Managed Medicaid	$11,184.92

SPINAL FLUID TAP DIAGNOSTIC

Professional

Both

$526.00

Service Code	CPT 62270
Hospital Charge Code	7982766
Hospital Revenue Code	981
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$368.20
Rate for Payer: Aetna of IA Medicare	$56.25
Rate for Payer: Amerigroup Medicaid	$58.16
Rate for Payer: Cash Price	$420.80
Rate for Payer: Cash Price	$420.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$57.38
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$56.25
Rate for Payer: Midlands Choice Commercial	$368.20
Rate for Payer: Oscar Health of IA Commercial	$97.31
Rate for Payer: Partners Health Alliance Commercial	$84.38

Spinal Fusion Except Cervical With MCC

Facility

$46,561.51

Service Code	MS-DRG 459
Hospital Charge Code	279
Min. Negotiated Rate	$45,886.71
Max. Negotiated Rate	$46,561.51
Rate for Payer: Amerigroup Medicaid	$46,336.58
Rate for Payer: Iowa Total Care Managed Medicaid	$45,886.71
Rate for Payer: Molina Healthcare Managed Medicaid	$46,561.51

Spinal Fusion Except Cervical Without MCC

Facility

$30,898.29

Service Code	MS-DRG 460
Hospital Charge Code	280
Min. Negotiated Rate	$30,450.49
Max. Negotiated Rate	$30,898.29
Rate for Payer: Amerigroup Medicaid	$30,749.02
Rate for Payer: Iowa Total Care Managed Medicaid	$30,450.49
Rate for Payer: Molina Healthcare Managed Medicaid	$30,898.29

Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection or Extensive Fusions With CC

Facility

$52,614.60

Service Code	MS-DRG 457
Hospital Charge Code	277
Min. Negotiated Rate	$51,852.07
Max. Negotiated Rate	$52,614.60
Rate for Payer: Amerigroup Medicaid	$52,360.42
Rate for Payer: Iowa Total Care Managed Medicaid	$51,852.07
Rate for Payer: Molina Healthcare Managed Medicaid	$52,614.60

Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection or Extensive Fusions With MCC

Facility

$71,214.80

Service Code	MS-DRG 456
Hospital Charge Code	276
Min. Negotiated Rate	$70,182.70
Max. Negotiated Rate	$71,214.80
Rate for Payer: Amerigroup Medicaid	$70,870.77
Rate for Payer: Iowa Total Care Managed Medicaid	$70,182.70
Rate for Payer: Molina Healthcare Managed Medicaid	$71,214.80

Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection or Extensive Fusions Without CC/MCC

Facility

$51,718.94

Service Code	MS-DRG 458
Hospital Charge Code	278
Min. Negotiated Rate	$50,969.39
Max. Negotiated Rate	$51,718.94
Rate for Payer: Amerigroup Medicaid	$51,469.09
Rate for Payer: Iowa Total Care Managed Medicaid	$50,969.39
Rate for Payer: Molina Healthcare Managed Medicaid	$51,718.94

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	$72.43
Max. Negotiated Rate	$361.90
Rate for Payer: Aetna of IA Medicare	$72.43
Rate for Payer: Amerigroup Medicaid	$74.89
Rate for Payer: Cash Price	$413.60
Rate for Payer: Cash Price	$413.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.92
Rate for Payer: Iowa Total Care Managed Medicaid	$73.88
Rate for Payer: Medical Associates Commercial	$137.62
Rate for Payer: Medical Associates Managed Medicare	$72.43
Rate for Payer: Midlands Choice Commercial	$361.90
Rate for Payer: Oscar Health of IA Commercial	$125.30
Rate for Payer: Partners Health Alliance Commercial	$108.64

Spinal Procedures With CC or Spinal Neurostimulators

Facility

$21,499.78

Service Code	MS-DRG 029
Hospital Charge Code	718
Min. Negotiated Rate	$21,188.18
Max. Negotiated Rate	$21,499.78
Rate for Payer: Amerigroup Medicaid	$21,395.91
Rate for Payer: Iowa Total Care Managed Medicaid	$21,188.18
Rate for Payer: Molina Healthcare Managed Medicaid	$21,499.78

Spinal Procedures With MCC

Facility

$36,436.63

Service Code	MS-DRG 028
Hospital Charge Code	717
Min. Negotiated Rate	$35,908.56
Max. Negotiated Rate	$36,436.63
Rate for Payer: Amerigroup Medicaid	$36,260.60
Rate for Payer: Iowa Total Care Managed Medicaid	$35,908.56
Rate for Payer: Molina Healthcare Managed Medicaid	$36,436.63

Spinal Procedures Without CC/MCC

Facility

$18,268.51

Service Code	MS-DRG 030
Hospital Charge Code	719
Min. Negotiated Rate	$18,003.74
Max. Negotiated Rate	$18,268.51
Rate for Payer: Amerigroup Medicaid	$18,180.25
Rate for Payer: Iowa Total Care Managed Medicaid	$18,003.74
Rate for Payer: Molina Healthcare Managed Medicaid	$18,268.51

SPINAL PUNCTURE LUMBAR

Facility

$406.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	964
Min. Negotiated Rate	$202.92
Max. Negotiated Rate	$1,487.44
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	$204.91
Rate for Payer: Amerigroup Medicare	$205.03
Rate for Payer: Cash Price	$324.80
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	$203.00
Rate for Payer: Iowa Total Care Managed Medicaid	$202.92
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Medical Associates Managed Medicare	$203.00
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: Molina Healthcare Managed Medicaid	$206.04
Rate for Payer: Molina Healthcare Managed Medicare	$205.92
Rate for Payer: Oscar Health of IA Commercial	$304.50
Rate for Payer: Partners Health Alliance Commercial	$304.50
Rate for Payer: United Healthcare Commercial	$365.40
Rate for Payer: United Healthcare Managed Medicare	$239.54
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

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 Tap Procedure

Facility

$602.00

Service Code	CPT 62270
Hospital Charge Code	8060782
Hospital Revenue Code	761
Min. Negotiated Rate	$300.88
Max. Negotiated Rate	$1,487.44
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	$303.83
Rate for Payer: Amerigroup Medicare	$304.01
Rate for Payer: Cash Price	$481.60
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	$301.00
Rate for Payer: Iowa Total Care Managed Medicaid	$300.88
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Medical Associates Managed Medicare	$301.00
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Molina Healthcare Managed Medicaid	$305.52
Rate for Payer: Molina Healthcare Managed Medicare	$305.33
Rate for Payer: Oscar Health of IA Commercial	$451.50
Rate for Payer: Partners Health Alliance Commercial	$451.50
Rate for Payer: United Healthcare Commercial	$541.80
Rate for Payer: United Healthcare Managed Medicare	$355.18
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

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

spironolactone 100 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10422027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
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	$0.81
Rate for Payer: Amerigroup Medicare	$0.81
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	$0.80
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Medical Associates Managed Medicare	$0.80
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Molina Healthcare Managed Medicare	$0.81
Rate for Payer: Oscar Health of IA Commercial	$1.20
Rate for Payer: Partners Health Alliance Commercial	$1.20
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	$0.72
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of IA Commercial	$1.30
Rate for Payer: Aetna of IA Medical Rental Products	$1.30
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.73
Rate for Payer: Amerigroup Medicare	$0.73
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	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.72
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: Molina Healthcare Managed Medicaid	$0.73
Rate for Payer: Molina Healthcare Managed Medicare	$0.73
Rate for Payer: Oscar Health of IA Commercial	$1.08
Rate for Payer: Partners Health Alliance Commercial	$1.08
Rate for Payer: United Healthcare Commercial	$1.30
Rate for Payer: United Healthcare Managed Medicare	$0.85

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	$1.30
Rate for Payer: Aetna of IA Commercial	$1.30
Rate for Payer: Aetna of IA Medical Rental Products	$1.30
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	$1.30

Splenectomy With CC

Facility

$16,168.14

Service Code	MS-DRG 800
Hospital Charge Code	542
Min. Negotiated Rate	$15,933.82
Max. Negotiated Rate	$16,168.14
Rate for Payer: Amerigroup Medicaid	$16,090.03
Rate for Payer: Iowa Total Care Managed Medicaid	$15,933.82
Rate for Payer: Molina Healthcare Managed Medicaid	$16,168.14

Splenectomy With MCC

Facility

$32,983.90

Service Code	MS-DRG 799
Hospital Charge Code	541
Min. Negotiated Rate	$32,505.87
Max. Negotiated Rate	$32,983.90
Rate for Payer: Amerigroup Medicaid	$32,824.56
Rate for Payer: Iowa Total Care Managed Medicaid	$32,505.87
Rate for Payer: Molina Healthcare Managed Medicaid	$32,983.90

Know your out-of-pocket cost for care.

All Charges