Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Splenectomy Without CC/MCC

Facility

$13,776.43

Service Code	MS-DRG 801
Hospital Charge Code	543
Min. Negotiated Rate	$13,576.77
Max. Negotiated Rate	$13,776.43
Rate for Payer: Amerigroup Medicaid	$13,709.88
Rate for Payer: Iowa Total Care Managed Medicaid	$13,576.77
Rate for Payer: Molina Healthcare Managed Medicaid	$13,776.43

Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh With CC/MCC

Facility

$7,891.65

Service Code	MS-DRG 537
Hospital Charge Code	344
Min. Negotiated Rate	$7,777.28
Max. Negotiated Rate	$7,891.65
Rate for Payer: Amerigroup Medicaid	$7,853.52
Rate for Payer: Iowa Total Care Managed Medicaid	$7,777.28
Rate for Payer: Molina Healthcare Managed Medicaid	$7,891.65

Sprains, Strains, and Dislocations of Hip, Pelvis and Thigh Without CC/MCC

Facility

$7,100.32

Service Code	MS-DRG 538
Hospital Charge Code	345
Min. Negotiated Rate	$6,997.41
Max. Negotiated Rate	$7,100.32
Rate for Payer: Amerigroup Medicaid	$7,066.02
Rate for Payer: Iowa Total Care Managed Medicaid	$6,997.41
Rate for Payer: Molina Healthcare Managed Medicaid	$7,100.32

SPRAVATO OBSERVATION

Professional

Both

$500.00

Service Code	CPT 99213
Hospital Charge Code	8829628
Hospital Revenue Code	983
Min. Negotiated Rate	$60.81
Max. Negotiated Rate	$109.46
Rate for Payer: Aetna of IA Medicare	$60.81
Rate for Payer: Amerigroup Medicaid	$62.88
Rate for Payer: Cash Price	$400.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.97
Rate for Payer: Iowa Total Care Managed Medicaid	$62.03
Rate for Payer: Medical Associates Commercial	$109.46
Rate for Payer: Medical Associates Managed Medicare	$60.81
Rate for Payer: Midlands Choice Commercial	$97.14
Rate for Payer: Oscar Health of IA Commercial	$103.38
Rate for Payer: Partners Health Alliance Commercial	$91.22
Rate for Payer: United Healthcare Commercial	$66.26

SQ/IM INJECTIONS ADMIN

Facility

$66.00

Service Code	CPT 96372
Hospital Charge Code	7984745
Hospital Revenue Code	761
Min. Negotiated Rate	$32.99
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	$33.31
Rate for Payer: Amerigroup Medicare	$33.33
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	$33.00
Rate for Payer: Iowa Total Care Managed Medicaid	$32.99
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$33.00
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$33.50
Rate for Payer: Molina Healthcare Managed Medicare	$33.48
Rate for Payer: Oscar Health of IA Commercial	$49.50
Rate for Payer: Partners Health Alliance Commercial	$49.50
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94

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

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	CPT C1713
Hospital Charge Code	8948786
Hospital Revenue Code	278
Min. Negotiated Rate	$956.62
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	$966.00
Rate for Payer: Amerigroup Medicare	$966.57
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	$957.00
Rate for Payer: Iowa Total Care Managed Medicaid	$956.62
Rate for Payer: Medical Associates Commercial	$1,435.50
Rate for Payer: Medical Associates Managed Medicare	$957.00
Rate for Payer: Midlands Choice Commercial	$1,339.80
Rate for Payer: Molina Healthcare Managed Medicaid	$971.36
Rate for Payer: Molina Healthcare Managed Medicare	$970.78
Rate for Payer: Oscar Health of IA Commercial	$1,435.50
Rate for Payer: Partners Health Alliance Commercial	$1,435.50
Rate for Payer: United Healthcare Commercial	$1,722.60
Rate for Payer: United Healthcare Managed Medicare	$1,129.26

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	CPT 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

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

STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE

Facility

$484.00

Hospital Charge Code	8046475
Hospital Revenue Code	272
Min. Negotiated Rate	$241.90
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	$244.27
Rate for Payer: Amerigroup Medicare	$244.42
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	$242.00
Rate for Payer: Iowa Total Care Managed Medicaid	$241.90
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Medical Associates Managed Medicare	$242.00
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: Molina Healthcare Managed Medicaid	$245.63
Rate for Payer: Molina Healthcare Managed Medicare	$245.48
Rate for Payer: Oscar Health of IA Commercial	$363.00
Rate for Payer: Partners Health Alliance Commercial	$363.00
Rate for Payer: United Healthcare Commercial	$435.60
Rate for Payer: United Healthcare Managed Medicare	$285.56

STENT INJECT

Facility

$3,636.00

Service Code	CPT V2632
Hospital Charge Code	8896002
Hospital Revenue Code	276
Min. Negotiated Rate	$1,817.27
Max. Negotiated Rate	$3,272.40
Rate for Payer: Aetna of IA Commercial	$3,272.40
Rate for Payer: Aetna of IA Medical Rental Products	$3,272.40
Rate for Payer: Aetna of IA Medicare	$2,072.52
Rate for Payer: Amerigroup Medicaid	$1,835.09
Rate for Payer: Amerigroup Medicare	$1,836.18
Rate for Payer: Cash Price	$2,908.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,727.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,818.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,817.27
Rate for Payer: Medical Associates Commercial	$2,727.00
Rate for Payer: Medical Associates Managed Medicare	$1,818.00
Rate for Payer: Midlands Choice Commercial	$2,545.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,845.27
Rate for Payer: Molina Healthcare Managed Medicare	$1,844.18
Rate for Payer: Oscar Health of IA Commercial	$2,727.00
Rate for Payer: Partners Health Alliance Commercial	$2,727.00
Rate for Payer: United Healthcare Commercial	$3,272.40
Rate for Payer: United Healthcare Managed Medicare	$2,145.24

STENT INJECT

Facility

$3,636.00

Service Code	CPT V2632
Hospital Charge Code	8896002
Hospital Revenue Code	276
Min. Negotiated Rate	$2,545.20
Max. Negotiated Rate	$3,272.40
Rate for Payer: Aetna of IA Commercial	$3,272.40
Rate for Payer: Aetna of IA Medical Rental Products	$3,272.40
Rate for Payer: Cash Price	$2,908.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,727.00
Rate for Payer: Medical Associates Commercial	$2,727.00
Rate for Payer: Midlands Choice Commercial	$2,545.20
Rate for Payer: United Healthcare Commercial	$3,272.40

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	$34.79
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	$35.13
Rate for Payer: Amerigroup Medicare	$35.15
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	$34.80
Rate for Payer: Iowa Total Care Managed Medicaid	$34.79
Rate for Payer: Medical Associates Commercial	$52.20
Rate for Payer: Medical Associates Managed Medicare	$34.80
Rate for Payer: Midlands Choice Commercial	$48.72
Rate for Payer: Molina Healthcare Managed Medicaid	$35.32
Rate for Payer: Molina Healthcare Managed Medicare	$35.30
Rate for Payer: Oscar Health of IA Commercial	$52.20
Rate for Payer: Partners Health Alliance Commercial	$52.20
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	CPT C1781
Hospital Charge Code	8578902
Hospital Revenue Code	278
Min. Negotiated Rate	$2,064.67
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: Aetna of IA Medicare	$2,354.67
Rate for Payer: Amerigroup Medicaid	$2,084.92
Rate for Payer: Amerigroup Medicare	$2,086.16
Rate for Payer: Cash Price	$3,304.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,098.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,065.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,064.67
Rate for Payer: Medical Associates Commercial	$3,098.25
Rate for Payer: Medical Associates Managed Medicare	$2,065.50
Rate for Payer: Midlands Choice Commercial	$2,891.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,096.48
Rate for Payer: Molina Healthcare Managed Medicare	$2,095.24
Rate for Payer: Oscar Health of IA Commercial	$3,098.25
Rate for Payer: Partners Health Alliance Commercial	$3,098.25
Rate for Payer: United Healthcare Commercial	$3,717.90
Rate for Payer: United Healthcare Managed Medicare	$2,437.29

STERISHIELD II DUAL LAYER AMNION PATCH 4X4

Facility

$4,131.00

Service Code	CPT 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

STIM SUP

Facility

$85.00

Service Code	CPT G0283 GO
Hospital Charge Code	1373552
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

STIM SUP

Facility

$85.00

Service Code	CPT G0283 GO
Hospital Charge Code	1373552
Hospital Revenue Code	430
Min. Negotiated Rate	$42.48
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: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$42.90
Rate for Payer: Amerigroup Medicare	$42.92
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	$42.50
Rate for Payer: Iowa Total Care Managed Medicaid	$42.48
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$42.50
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$43.14
Rate for Payer: Molina Healthcare Managed Medicare	$43.11
Rate for Payer: Oscar Health of IA Commercial	$63.75
Rate for Payer: Partners Health Alliance Commercial	$63.75
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15

Stomach, Esophageal and Duodenal Procedures With CC

Facility

$17,237.02

Service Code	MS-DRG 327
Hospital Charge Code	177
Min. Negotiated Rate	$16,987.21
Max. Negotiated Rate	$17,237.02
Rate for Payer: Amerigroup Medicaid	$17,153.75
Rate for Payer: Iowa Total Care Managed Medicaid	$16,987.21
Rate for Payer: Molina Healthcare Managed Medicaid	$17,237.02

Stomach, Esophageal and Duodenal Procedures With MCC

Facility

$33,003.58

Service Code	MS-DRG 326
Hospital Charge Code	176
Min. Negotiated Rate	$32,525.27
Max. Negotiated Rate	$33,003.58
Rate for Payer: Amerigroup Medicaid	$32,844.15
Rate for Payer: Iowa Total Care Managed Medicaid	$32,525.27
Rate for Payer: Molina Healthcare Managed Medicaid	$33,003.58

Stomach, Esophageal and Duodenal Procedures Without CC/MCC

Facility

$9,486.12

Service Code	MS-DRG 328
Hospital Charge Code	178
Min. Negotiated Rate	$9,348.64
Max. Negotiated Rate	$9,486.12
Rate for Payer: Amerigroup Medicaid	$9,440.29
Rate for Payer: Iowa Total Care Managed Medicaid	$9,348.64
Rate for Payer: Molina Healthcare Managed Medicaid	$9,486.12

Stone (Calculus) Analysis DMCL

Facility

$139.00

Service Code	CPT 82365
Hospital Charge Code	8505620
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Stone (Calculus) Analysis DMCL

Facility

$139.00

Service Code	CPT 82365
Hospital Charge Code	8505620
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

STOOL CULTURE

Facility

$77.00

Service Code	CPT 87045
Hospital Charge Code	633904
Hospital Revenue Code	306
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of IA Commercial	$69.30
Rate for Payer: Aetna of IA Medical Rental Products	$69.30
Rate for Payer: Cash Price	$61.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.75
Rate for Payer: Medical Associates Commercial	$57.75
Rate for Payer: Midlands Choice Commercial	$53.90
Rate for Payer: United Healthcare Commercial	$69.30

STOOL CULTURE

Facility

$77.00

Service Code	CPT 87045
Hospital Charge Code	633904
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of IA Commercial	$69.30
Rate for Payer: Aetna of IA Medical Rental Products	$69.30
Rate for Payer: Aetna of IA Medicare	$43.89
Rate for Payer: Amerigroup Medicaid	$38.86
Rate for Payer: Amerigroup Medicare	$38.88
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.50
Rate for Payer: Iowa Total Care Managed Medicaid	$38.48
Rate for Payer: Medical Associates Commercial	$57.75
Rate for Payer: Medical Associates Managed Medicare	$38.50
Rate for Payer: Midlands Choice Commercial	$53.90
Rate for Payer: Molina Healthcare Managed Medicaid	$39.08
Rate for Payer: Molina Healthcare Managed Medicare	$39.05
Rate for Payer: Oscar Health of IA Commercial	$57.75
Rate for Payer: Partners Health Alliance Commercial	$57.75
Rate for Payer: United Healthcare Commercial	$69.30
Rate for Payer: United Healthcare Managed Medicare	$45.43
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

Know your out-of-pocket cost for care.

All Charges