Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Speech Language Pathology Video Swallow

Facility

$389.00

Service Code	CPT 74230
Hospital Charge Code	985772
Hospital Revenue Code	320
Min. Negotiated Rate	$272.30
Max. Negotiated Rate	$350.10
Rate for Payer: Aetna of IA Commercial	$350.10
Rate for Payer: Aetna of IA Medical Rental Products	$350.10
Rate for Payer: Cash Price	$311.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$291.75
Rate for Payer: Medical Associates Commercial	$291.75
Rate for Payer: Midlands Choice Commercial	$272.30
Rate for Payer: United Healthcare Commercial	$350.10

SPEECH/OTHR COMMUNCATE INDIVIDUAL TX

Facility

$230.00

Service Code	CPT 92507 GN
Hospital Charge Code	5526782
Hospital Revenue Code	440
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

SPEECH/OTHR COMMUNCATE INDIVIDUAL TX

Facility

$230.00

Service Code	CPT 92507 GN
Hospital Charge Code	5526782
Hospital Revenue Code	440
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$228.83
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.54
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.38
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: Molina Healthcare Managed Medicaid	$133.31
Rate for Payer: Partners Health Alliance Commercial	$119.02
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70
Rate for Payer: Wellmark IA HMO WHPI	$207.74
Rate for Payer: Wellmark IA PPO	$228.83

SPHINCTEROTOMY ER CHARGE

Professional

Both

$530.00

Hospital Charge Code	8069012
Hospital Revenue Code	981
Min. Negotiated Rate	$371.00
Max. Negotiated Rate	$397.50
Rate for Payer: Cash Price	$424.00
Rate for Payer: Medical Associates Commercial	$397.50
Rate for Payer: Midlands Choice Commercial	$371.00
Rate for Payer: Partners Health Alliance Commercial	$397.50

SPIKED GRIDLOCK ANKLE WASHER

Facility

$288.00

Service Code	HCPCS C1713
Hospital Charge Code	8780887
Hospital Revenue Code	278
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of IA Commercial	$259.20
Rate for Payer: Aetna of IA Medical Rental Products	$259.20
Rate for Payer: Cash Price	$230.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$216.00
Rate for Payer: Medical Associates Commercial	$216.00
Rate for Payer: Midlands Choice Commercial	$201.60
Rate for Payer: United Healthcare Commercial	$259.20

SPIKED GRIDLOCK ANKLE WASHER

Facility

$288.00

Service Code	HCPCS C1713
Hospital Charge Code	8780887
Hospital Revenue Code	278
Min. Negotiated Rate	$129.60
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of IA Commercial	$259.20
Rate for Payer: Aetna of IA Medical Rental Products	$259.20
Rate for Payer: Aetna of IA Medicare	$164.16
Rate for Payer: Amerigroup Medicaid	$166.12
Rate for Payer: Amerigroup Medicare	$130.90
Rate for Payer: Cash Price	$230.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$216.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$129.60
Rate for Payer: Iowa Total Care Managed Medicaid	$164.51
Rate for Payer: Medical Associates Commercial	$216.00
Rate for Payer: Medical Associates Managed Medicare	$129.60
Rate for Payer: Midlands Choice Commercial	$201.60
Rate for Payer: Molina Healthcare Managed Medicaid	$166.92
Rate for Payer: Partners Health Alliance Commercial	$149.04
Rate for Payer: United Healthcare Commercial	$259.20
Rate for Payer: United Healthcare Managed Medicare	$169.92

SPIKED GRIDLOCK SCREW WASHER LARGE

Facility

$288.00

Service Code	HCPCS C1713
Hospital Charge Code	8740441
Hospital Revenue Code	278
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of IA Commercial	$259.20
Rate for Payer: Aetna of IA Medical Rental Products	$259.20
Rate for Payer: Cash Price	$230.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$216.00
Rate for Payer: Medical Associates Commercial	$216.00
Rate for Payer: Midlands Choice Commercial	$201.60
Rate for Payer: United Healthcare Commercial	$259.20

SPIKED GRIDLOCK SCREW WASHER LARGE

Facility

$288.00

Service Code	HCPCS C1713
Hospital Charge Code	8740441
Hospital Revenue Code	278
Min. Negotiated Rate	$129.60
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of IA Commercial	$259.20
Rate for Payer: Aetna of IA Medical Rental Products	$259.20
Rate for Payer: Aetna of IA Medicare	$164.16
Rate for Payer: Amerigroup Medicaid	$166.12
Rate for Payer: Amerigroup Medicare	$130.90
Rate for Payer: Cash Price	$230.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$216.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$129.60
Rate for Payer: Iowa Total Care Managed Medicaid	$164.51
Rate for Payer: Medical Associates Commercial	$216.00
Rate for Payer: Medical Associates Managed Medicare	$129.60
Rate for Payer: Midlands Choice Commercial	$201.60
Rate for Payer: Molina Healthcare Managed Medicaid	$166.92
Rate for Payer: Partners Health Alliance Commercial	$149.04
Rate for Payer: United Healthcare Commercial	$259.20
Rate for Payer: United Healthcare Managed Medicare	$169.92

SPIKED WASHER FOR 4.5 SCREW

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8047046
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

SPIKED WASHER FOR 4.5 SCREW

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8047046
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

SPINAL ANESTHESIA I

Facility

$789.00

Hospital Charge Code	8059078
Hospital Revenue Code	370
Min. Negotiated Rate	$355.05
Max. Negotiated Rate	$710.10
Rate for Payer: Aetna of IA Commercial	$710.10
Rate for Payer: Aetna of IA Medical Rental Products	$710.10
Rate for Payer: Aetna of IA Medicare	$449.73
Rate for Payer: Amerigroup Medicaid	$455.10
Rate for Payer: Amerigroup Medicare	$358.60
Rate for Payer: Cash Price	$631.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$355.05
Rate for Payer: Iowa Total Care Managed Medicaid	$450.68
Rate for Payer: Medical Associates Commercial	$591.75
Rate for Payer: Medical Associates Managed Medicare	$355.05
Rate for Payer: Midlands Choice Commercial	$552.30
Rate for Payer: Molina Healthcare Managed Medicaid	$457.30
Rate for Payer: Partners Health Alliance Commercial	$408.31
Rate for Payer: United Healthcare Commercial	$710.10
Rate for Payer: United Healthcare Managed Medicare	$465.51

SPINAL ANESTHESIA I

Facility

$789.00

Hospital Charge Code	8059078
Hospital Revenue Code	370
Min. Negotiated Rate	$552.30
Max. Negotiated Rate	$710.10
Rate for Payer: Aetna of IA Commercial	$710.10
Rate for Payer: Aetna of IA Medical Rental Products	$710.10
Rate for Payer: Cash Price	$631.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.75
Rate for Payer: Medical Associates Commercial	$591.75
Rate for Payer: Midlands Choice Commercial	$552.30
Rate for Payer: United Healthcare Commercial	$710.10

SPINAL ANESTHESIA II

Facility

$958.00

Hospital Charge Code	8059590
Hospital Revenue Code	370
Min. Negotiated Rate	$670.60
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: Cash Price	$766.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$718.50
Rate for Payer: Medical Associates Commercial	$718.50
Rate for Payer: Midlands Choice Commercial	$670.60
Rate for Payer: United Healthcare Commercial	$862.20

SPINAL ANESTHESIA II

Facility

$958.00

Hospital Charge Code	8059590
Hospital Revenue Code	370
Min. Negotiated Rate	$431.10
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	$552.57
Rate for Payer: Amerigroup Medicare	$435.41
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	$431.10
Rate for Payer: Iowa Total Care Managed Medicaid	$547.21
Rate for Payer: Medical Associates Commercial	$718.50
Rate for Payer: Medical Associates Managed Medicare	$431.10
Rate for Payer: Midlands Choice Commercial	$670.60
Rate for Payer: Molina Healthcare Managed Medicaid	$555.26
Rate for Payer: Partners Health Alliance Commercial	$495.76
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	$206.55
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	$264.75
Rate for Payer: Amerigroup Medicare	$208.62
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	$206.55
Rate for Payer: Iowa Total Care Managed Medicaid	$262.18
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$206.55
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$266.04
Rate for Payer: Partners Health Alliance Commercial	$237.53
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81

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 DISORDERS AND INJURIES WITH CC/MCC

Facility

$18,792.56

Service Code	MSDRG 052
Min. Negotiated Rate	$18,520.19
Max. Negotiated Rate	$18,792.56
Rate for Payer: Amerigroup Medicaid	$18,701.76
Rate for Payer: Iowa Total Care Managed Medicaid	$18,520.19
Rate for Payer: Molina Healthcare Managed Medicaid	$18,792.56

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$12,795.60

Service Code	MSDRG 053
Min. Negotiated Rate	$12,610.15
Max. Negotiated Rate	$12,795.60
Rate for Payer: Amerigroup Medicaid	$12,733.78
Rate for Payer: Iowa Total Care Managed Medicaid	$12,610.15
Rate for Payer: Molina Healthcare Managed Medicaid	$12,795.60

SPINAL FLUID TAP DIAGNOSTI C

Professional

Both

$262.00

Service Code	CPT 62270
Hospital Charge Code	4662901
Hospital Revenue Code	983
Min. Negotiated Rate	$113.34
Max. Negotiated Rate	$323.50
Rate for Payer: Amerigroup Medicaid	$114.45
Rate for Payer: Cash Price	$209.60
Rate for Payer: Cash Price	$209.60
Rate for Payer: Iowa Total Care Managed Medicaid	$113.34
Rate for Payer: Medical Associates Commercial	$196.50
Rate for Payer: Midlands Choice Commercial	$183.40
Rate for Payer: Molina Healthcare Managed Medicaid	$113.90
Rate for Payer: Partners Health Alliance Commercial	$196.50
Rate for Payer: United Healthcare Commercial	$210.02
Rate for Payer: Wellmark IA HMO WHPI	$275.00
Rate for Payer: Wellmark IA PPO	$323.50

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	$1,679.15
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

SPINAL FLUID TAP DIAGNOSTIC

Professional

Both

$526.00

Service Code	CPT 62270
Hospital Charge Code	7982766
Hospital Revenue Code	981
Min. Negotiated Rate	$113.34
Max. Negotiated Rate	$394.50
Rate for Payer: Amerigroup Medicaid	$114.45
Rate for Payer: Cash Price	$420.80
Rate for Payer: Cash Price	$420.80
Rate for Payer: Iowa Total Care Managed Medicaid	$113.34
Rate for Payer: Medical Associates Commercial	$394.50
Rate for Payer: Midlands Choice Commercial	$368.20
Rate for Payer: Molina Healthcare Managed Medicaid	$113.90
Rate for Payer: Partners Health Alliance Commercial	$394.50
Rate for Payer: United Healthcare Commercial	$210.02
Rate for Payer: Wellmark IA HMO WHPI	$275.00
Rate for Payer: Wellmark IA PPO	$323.50

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$60,191.35

Service Code	MSDRG 457
Min. Negotiated Rate	$59,318.99
Max. Negotiated Rate	$60,191.35
Rate for Payer: Amerigroup Medicaid	$59,900.55
Rate for Payer: Iowa Total Care Managed Medicaid	$59,318.99
Rate for Payer: Molina Healthcare Managed Medicaid	$60,191.35

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$81,470.07

Service Code	MSDRG 456
Min. Negotiated Rate	$80,289.30
Max. Negotiated Rate	$81,470.07
Rate for Payer: Amerigroup Medicaid	$81,076.45
Rate for Payer: Iowa Total Care Managed Medicaid	$80,289.30
Rate for Payer: Molina Healthcare Managed Medicaid	$81,470.07

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$59,166.71

Service Code	MSDRG 458
Min. Negotiated Rate	$58,309.20
Max. Negotiated Rate	$59,166.71
Rate for Payer: Amerigroup Medicaid	$58,880.86
Rate for Payer: Iowa Total Care Managed Medicaid	$58,309.20
Rate for Payer: Molina Healthcare Managed Medicaid	$59,166.71

Know your out-of-pocket cost for care.

All Charges